Verification Worksheet Dependent Student Template - 2015-2016 Page 3
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1
2
3
4NAME ____________________________________________________________________
Last
First
Student ID Number
MI
E. Supplemental Nutrition Assistance Program (SNAP)
Check the appropriate box below:
No one in listed in the household received SNAP benefits in 2013 or 2014.
One of the persons listed in household received SNAP benefits in 2013 or 2014. If asked by the student’s school, I will provide documentation
of the receipt of SNAP benefits during 2013 and/or 2014.
F. Child support paid
Check the appropriate box below:
No child support was paid for individuals outside of the household for 2014.
One (or both) of the student’s parents listed in Section B of this worksheet paid child support in 2014. The parent has indicated below the name
of the person who paid the child support, the name of the person to whom the child support was paid, the names of the children for whom child
support was paid, and the total annual amount of child support that was paid in 2014 for each child. If asked by the school, we will provide
documentation of the payment of child support. If you need more space, attach a separate page that includes the student’s name and “V”
number on the top.
Name of Person who
Name of Person to whom
Name of Child for whom
Amount of Child Support
Paid Child Support
Child Support was Paid
Support was
Paid in 2014
Paid
Example: Joe Jones
Jane Doe
Jake Jones
$6,000
G. Other Untaxed Income
Complete this section if you or your parents had untaxed income in 2014.
If any Item does not apply enter “N/A” where a response is requested or enter “0” if an amount is requested.
Name of Person Who had Untaxed Income
Type of Untaxed Income Received
Student Amount
Parent Amount
Example: Jim Jones
Money received or paid on the students behalf
$500.00
0
Payments to tax-deferred pension and savings plans
Housing, food, and other living allowances paid to
members of the military, clergy
Veterans noneducation benefits
Money received or paid on the students behalf
Other untaxed income
Other Untaxed Income Includes: Untaxed income not reported elsewhere on this form, workers’ compensation, disability, black lung benefits,
untaxed portions of health savings accounts from IRS Form 1040 line 25, railroad retirement benefits, etc.
Do Not Include: Student aid, earned income credit, additional child tax credit, TANF, untaxed social security benefits, SSI, WIA, combat pay,
benefits from flexible spending arrangements, foreign income exclusion or credit for federal tax on special fuels.
Office of Financial Aid
Grace E. Harris Hall Student Service Center
1015 Floyd Ave., 1st Floor
P.O. Box 843026
Richmond, VA 23284-2520
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(804) 828-6669
Fax (804) 827-0060
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VCU is an EEO/AA institution. ENR1314-121
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